Chapter 26, Problem 15RQ

Summary Introduction

The documentation is one of the important practices in the nursing care plan as well as for hospital procedure for patient information that are legalized. The documentation by the nurse gives important information about the patient. The documentation will be in the form of medical records, nursing records, and handing-over documents. The medical record holds the information about the patient what type of disease the patient suffering. The nursing records contain the in-ward documents from the time the patient got admitted, records of the patient vitals, medicines are taken, and till the time of discharge. The informatics in nursing aids in the documentation, research, education, and administration.